| Aim : i.) to gain insight in current grade of implementation of IIT and to identify general obstacles/barriers to implementing IIT; to inventory the presently locally applied IIT-protocols in the Netherlands, for optimizing the IIT-protocol to use - (ii.) to identify local obstacles/barriers to IIT that need to be tackled in participating centers of this project of implementation of IIT - (iii.) to train caregivers using an optimized IIT-algorithm - (iv.) to stepwise implement IIT, first by IC-physicians and IC-nurses, followed by IC-nurses alone, and to compare them in respect to safety and efficiency of IIT - (v.) to use the information that comes from (i.-iv.) for national implementation of IIT.Objective i. - formal survey with representative IC-physicians and -nurses from all IC-departments, asking both for their present practice and past experiences regarding glucose control, reasons for not implementing IIT (or only partially implementing IIT), fears and suspected or known obstacles to (or facilitators for) IIT. The factors suggested to play a role in defective implementation (see problem definition ) are explicitly asked and looked for.Objective ii. - repetitive site visits, during which local obstacles/barriers are recognized during interviews with IC-physicians and -nurses from the centers that participate in the study as mentioned under (iv.). Objective iii. - emphasize the importance of using a protocol aiming at BGCs between 4.4 and 6.1 mmol/L and frequent BGC-measurements, train local IC-physicians and local IC-nurses in using the optimized protocol, give insight in predisposing factors for hypoglycemia. Aspects that need attention as found with (I and ii.) are highlighted during the training of IIT.Objective iv. - IIT be applied by IC-physicians and IC-nurses together in a first episode, followed by a second episode during which IIT is applied by IC-nurses alone. The information that comes from the several previous steps as proposed above will be used in the training.Objective v. - IC-physicians and IC-nurses will receive feedback on the formal survey, and information regarding safety and efficacy of IIT performed by IC-physicians or IC-nurses. For this we will contact these caregivers directly, as well as via interactive meetings and via presentations at meetings/publications in (inter-) national journals. A national guideline will be written and local workshops will be organized. Intensive insulin therapy (IIT) aiming at normoglycemia reduces mortality and morbidity of intensive care (IC)-patients. Several aspects of IIT hamper its implementation in daily practice, one hampering factor is the increased risk for potentially dangerous hypoglycemia. Although arguments plea for IIT being applied by IC-nurses, it is suggested that IC-nurse lack sufficient background information to safely apply IIT, especially when IIT aims at the lower normal limit of blood glucose concentrations (BGCs). The objective of the present proposal is safe and broad implementation of IIT targeting at normoglycemia. We designed a conceptual implementation framework for implementation of IIT, consisting of (i.) a national survey into the grade of IIT-implementation in Dutch IC s and presently locally applied IIT-protocols; the obtained information is used to optimize a locally developed IIT-protocol; potential obstacles to IIT are inventoried and rationalized; (ii.) site visits with IC-physicians and -nurses are used to search for such obstacles to IIT; (iii.) this is followed by the training of these healthcare workers, and local obstacles are solved; (iv.) in 2 years we plan to step-wise implement IIT, first by IC-physicians and IC-nurses, followed by IIT applied by IC-nurses alone; (v.) the obtained information will be used to develop a national guideline for IIT and to help implementation in all Dutch IC s, by means of symposia, workshops and congress-meetings. The survey is held in all Dutch ICs; interviews are held in the participating centers. The duration of the two consecutive periods under (iv.) is chosen to allow adequate comparison (2 x ¾ year, powered on the incidence of severe hypoglycemia in a former pilot-study; 1770 patients are to be recruited in each periods; 4 ICs with 10-12 beds with an average length of stay of 4 days). |
